Medicaid Managed Care Policies Relevant To The Development And Operation Of Peer Outreach And Education Programs

Over the past few years Medicaid managed care has grown significantly in enrollment and program complexity. According to the report on the 1996 survey of Medicaid managed care initiatives prepared by the National Academy for State Health Policy (NASHP) most of the recent growth in Medicaid managed care activity was in state use of risk-based programs while state reliance on Primary Care Case Management (PCCM) programs declined. The survey roughly estimates the number of Medicaid beneficiaries enrolled in at least one managed care program to be between 12 and 13 million. Only two states (Alaska and Wyoming) had no operational Medicaid managed care program as of the end of 1996. Thirty-eight states reported operating one or more risk-based managed care programs in 1996 (an increase from 32 states in 1994). Thirty-two states operated at least one PCCM program in 1996, a decline from 33 programs reported in 1994.

The purpose of this paper is to discuss the current Medicaid managed care policies and specific state policies and initiatives that are relevant to the development and operation of peer outreach and education programs. The paper will also highlight changes to the Medicaid policies due to the Balanced Budget Act (BBA) of 1997 that are relevant to this same topic.

The five general areas of interest related to the Medicaid policies are:

1. Provisions for outreach and education for marketing and enrollment.

2. Provisions for outreach and education for use of the health plan.

3. Requirements for preventive services and the standards (if any) to be achieved.

4. Requirements for program outcome measures used for evaluation.

5. Initiatives involving the employment of Medicaid recipients.

The NASHP 1996 survey found some significant changes in outreach for marketing and enrollment since the 1994 survey. In 1994, most risk-contracting states reported that both the government and health plans shared responsibility for marketing. In 1996, only sixteen states had both the health plan and the government involved in marketing. Ten states (AL, AZ, CO, KS, NV, NH, OR, RI, UT, and WA) reported relying solely on government for marketing and outreach (there were only three such states in 1994). Ten other states (GA, IL, IN, MI, MO, MT, NC, PA, TX, and VA) reported having no government involvement in actual outreach and marketing but rely on health plan and/or health benefit managers or enrollment broker. Only Michigan leaves the marketing solely up to the health plans with no government or health benefits manager involvement.

One big change since the 1994 survey is the use of health benefit managers in risk contracting programs – an increase from eight states in 1994 to 18 states in 1996. Five states reported that responsibility for marketing lies solely with a private health benefits manager for all populations. There was also an increase in the use of health benefit managers for PCCM programs – 14 reported in 1996 compared to eight states in 1994. The increased use of health benefit managers or enrollment brokers is due to a number of factors. States have curtailed health plan activities in marketing and enrollment because of past abuses by some health plan marketing representatives. This has also been done to ensure that enrollees receive a balanced presentation of their options and to help the beneficiary enroll in the plan that best meets his or her needs. Another factor for the states’ shift to the use of health benefit managers is the difficulty of getting authority to hire state staff to perform marketing and enrollment functions.

All but three of the 38 states operating risk-based programs in 1996 reported using the welfare/eligibility office for marketing, outreach or enrollment (an decrease from six states in 1994). Most states also reported using a variety of outreach strategies in the community. Only six states (Alabama, Colorado, Nevada, New Hampshire, Pennsylvania, and South Carolina) reported not using strategies that employ outreach in the community (i.e., churches, schools, public events, and/or public housing) which is a significant increase from the 1994 survey when only eight states reported using community-based venues for outreach. States also reported using a variety of techniques for outreach related to enrollment ranging from direct education sessions (30 states) and brochures or flyers (35 states) to the use of HMO report cards (two states). Fifteen risk-based programs and ten PCCM programs also reported using consumer groups to inform beneficiaries. The outreach and education strategies represent a commitment by the states to ensure that all beneficiaries receive the information each individual needs to select a health plan.

Regarding the issue of mandatory versus voluntary enrollment, 31 of 38 state risk-based programs reported having mandatory enrollment programs where Medicaid beneficiaries are required to select one of the managed care plan options. If the beneficiary fails to select a plan, they are automatically assigned to a plan. They do not have the option of remaining on fee-for-service for their Medicaid services. Most states also reported enrollment polices consistent across all eligibility groups though there are often certain subgroups that are either prohibited from enrolling into Medicaid managed care or that are allowed to disenroll from an otherwise mandatory program. The reasons for these "enrollment carve-outs" (as they are referred to) are to minimize administrative complexity (e.g., when a person has more than one source of health care coverage), to avoid a situation where there may be duplicate payments for services (e.g., for institutionalized beneficiaries whose benefits already include health services) and because the managed care system is not viewed as being adequate to meet the needs of certain groups such as chronically ill children. Currently, the most common carve-out reported by the states are people who are eligible for Medicare.

The biggest enrollment development reported in the 1996 survey is the growth of risk-based programs that include, or are designed specifically for, the disabled (SSI children or adults with special health needs). States with PCCM programs for SSI children grew from 15 state programs in 1994 to 22 in 1996. Risk-based programs for this group of children doubled during this same time period from 12 states to 24 states. This increase indicates that states are interested in folding more of the total Medicaid population into managed care arrangements, even the groups with complex and costly health, medical and social needs.

There are several opportunities for peer outreach and education programs to assist with enrollment of Medicaid beneficiaries into managed care programs. There are currently serious concerns over the default rate (where the individual does not select a plan and/or a primary care physician and is automatically assigned or defaulted to one of the available plan/PCP options) for current state managed care programs. Peer outreach and education can assist plans and enrollment brokers with educating Medicaid beneficiaries about their options for participation and the requirement that they select a plan as well as a primary care physician in many situations. Peer outreach workers can also help educate beneficiaries about how to select a plan and provider that will best meet his or her needs.

As noted above, fifteen risk programs and ten PCCM programs reported in the 1996 survey using consumer groups for outreach, education and promotion of enrollment. Also, reported under the "Required services that enable enrollees to use mc [managed care] services more effectively" on the table for "Scope of Capitated Services" by state are two state required services that relate to peer outreach and education. These are the use of "indigenous community outreach workers on site" and the use of "outreach workers for home follow-up visits". In the 1996 survey seven states (AZ, CT, DE, NE, NY, UT, and WI) reported the use of indigenous community outreach workers for at least a portion of the Medicaid population served. Nine states (CT, DE, DC, HI, NE, NJ, NY, PA and WI) reported using outreach workers for home follow-up visits. There was no other mention of these required services found in the report.

In general states are trying to ensure that enrollees receive basic information about how to access services before the plan enrollment takes effect. If the state or an enrollment broker/health benefits manager help an enrollee select a health plan, usually some of the basic rules about managed care are also explained (e.g., the role of the primary care physician, how to access emergency and family planning services, who to call if there is a problem, etc.). Although a variety of techniques are used to educate the beneficiary about the use of the health plan, the strategies used for providing initial information about the plan and use of the plan are often not sufficient to ensure that enrollees know how to access the care they need when they need it. As with health plan enrollment for any population (commercial, Medicare, etc.), most people do not closely study or easily retain information that is not immediately pertinent. This problem is further magnified if the information is only provided once at the end of a long day in a Medicaid eligibility office which is often the case with many programs.

States and plans reported using several different strategies to address these problems or issues. Since it has been found that people are more likely to remember information that they have talked about and not simply listened to, the format of the enrollment and education sessions can influence the amount of information the enrollee retains. More interactive strategies include the use of customer service lines, state hotlines, and ombudsmen which all can help provide information to enrollees about the use of their health plan.

Another effective method for educating enrollees is through education of the providers in the plan. The reason this method can be so effective is that providers see enrollees when they are concerned about how to access health care and thus are more likely to retain the information. Also, a discussion in the provider’s office is one-on-one and specifically related to the needs of the individual enrollee. To increase this strategy for educating enrollees, several states have placed specific requirements for provider education into their health plan contracts. As with any one strategy, there are drawbacks to using providers for enrollee education. For one, providers tend to be very busy and may not be able to spend enough time with the enrollee to educate them about the plan. Also, if the provider either doesn’t know or doesn’t tell the enrollee about everything covered or included under the plan and the enrollee has no independent source for this information, the enrollee may not access all the care that they require.

Another critical aspect of education and outreach is the effectiveness with which states educate providers and health plans about the multiple needs and the complications of poverty for this population – needs and issues which go beyond the purely medical. These complications include transportation problems, lack of child care, poor living conditions, difficulty in getting time off for medical appointments and often having to face the choice of heating their homes and paying rent or putting food on the table for their children against the importance of a physical check-up – even if it is covered by Medicaid. These non-medical concerns are a new aspect of care for many health plans and providers so they need to be educated as to what questions to ask, how to engender trust, and how to know what resources are available in the community (i.e., available social services to help with non-medical concerns).

The following comments on the BBA are summarized from an analysis written by the National Health Law Program, the National Center for Youth Law, the National Senior Citizens Law Center, and the Center for Medicare Advocacy.

The first area of relevance in the BBA are the new conditions that are placed on the availability of federal money for enrollment broker activity. First, the broker must be independent of managed care organizations and all health care providers in the state (whether or not they participate in the Medicaid program) and second, no person who is an owner, an employee, or contracting with the broker can have a financial interest in a managed care entity or health care provider. There is nothing in current Medicaid provisions or the BBA that specifies the qualifications for a broker even though repeated and numerous problems with enrollment brokers have been identified by the states. The analysis recommends that HCFA provide guidance in terms of minimum qualifications for brokers to include knowledge of the population served, the delivery system and provider capabilities, and the capacity of the plans to meet the needs of the population.

Another area of relevance in the BBA are a number of important consumer protections that have been added to the Medicaid Act to help prevent marketing fraud by managed care entities. These include:

Managed care entities, including their agents and independent contractors, may not distribute marketing material without the prior approval of the state or which contains false information. The state must consult with a medical care advisory committee as part of the process of review and approval.

Managed care entities must comply with procedures (to be prescribed by the Secretary) to ensure that individuals are provided accurate oral and written information sufficient to make an informed decision whether or not to enroll.

Managed care entities shall not, directly or indirectly, conduct door-to-door, telephonic, or other ‘cold-call’ marketing.

Although some of these provisions are already included in federal regulations and similar provisions are increasingly being implemented by states through their contracts, the new law is still significant. It is now mandatory in nature, it is more extensive than protections contained in most contracts, and it applies to all managed care entities (both risk-based and PCCM programs).

Regarding the provision of information to Medicaid managed care recipients, the BBA specifies that states, enrollment brokers, and managed care entities must provide all enrollment notices and informational and instructional materials relating to the managed care entities "in a manner and form which may be easily understood by enrollees and potential enrollees" who are eligible for Medicaid. In a separate provision, the legislation requires the state to inform the enrollee of any benefits to which the enrollee may be entitled under the Medicaid program but which are not available through the managed care entity. However, in an obvious blow to consumer-centered care and current efforts to increase educational efforts and the understanding of managed care and the use of the Medicaid managed care health plans, the BBA states that much of the information need only be provided if the consumer asks for it.

In the 1996 NASHP survey, the states reported no significant changes in the scope of services provided under their managed care programs except for the emerging use of risk-based specialty services (e.g., mental health) carve-out programs. The survey provided the opportunity for the states to identify 28 possible Medicaid services as being covered under a risk contract. The majority of the 38 states with risk-based programs reported contracting for at least 20 of these.

It is notable that NASHP didn’t place any special emphasis on required preventive services in either the survey instrument or their report in spite of this being one of the key benefits of moving Medicaid beneficiaries to managed care. Preventive as well as overall, comprehensive services are important for the Medicaid population because families with children on Medicaid often have more complex needs and are at greater risk for serious health problems than commercial populations. There were a few comments about preventive care in the one chapter of the NASHP survey report (Chapter 4, Health Care for Mothers). The emphasis was on the disincentives for the Medicaid managed care plans to emphasize preventive care when many Medicaid recipients are not enrolled in any one health plan for a long time period due to fragmented eligibility, frequent moves, and the ability of many health plan enrollees to switch plans.

One way many states have addressed this issue is by clarifying in the state’s contract with the health plan that the plan is responsible for the provision of preventive care. Some states even specifically define what preventive care means. For example, Oregon specifies and defines in its contract the required preventive services to be provided by the plan’s primary care providers. Another way that the states focus on preventive services is by requiring that the health plans provide some version of HEDIS data (27 of the 38 states with risk-based contracts require the plans to provide this data). HEDIS has several measures that get at the use of preventive care in general, such as: utilization of preventive ambulatory services by adults, advising smokers to quit, availability of primary care providers, mental health utilization and breast and cervical cancer screening. There is further information on HEDIS in another section of this report (Role of Prevention under Medicaid Managed Care).

Preventive services included on the survey list of possible Medicaid services are physician visits, prenatal care/OB care, EPSDT screens and extended treatment services, family planning, prescription drugs, dental, hearing services, and vision services. All 38 states except for Alabama contract for physician visits and EPSDT and extended treatment. Only Alabama and Kansas do not cover family planning at all under risk contract. Fourteen states allow an out-of-network family planning service provider to bill Medicaid directly while 20 states reported requiring contracting plans to pay for out-of-network coverage (these groups of states include some overlap).

Also in a special chapter in the 1996 survey report on health care for children, there is further discussion regarding the Medicaid provisions specific to the Early and Periodic, Screening, Diagnosis and Treatment Program (EPSDT). These provisions require all states to provide all medically necessary follow up treatment to correct or ameliorate any condition discovered during a screening – even if a service, such as dental, is not available to adults in that state. Federal regulations also require that states identify Medicaid beneficiaries under age 21 and their families, inform them about EPSDT services and the importance of preventive health care, and assist with making appointments for their children’s check-ups. The provisions require that Medicaid agencies track families to ensure provision of both screenings and adequate care for follow-up. State agencies must also collect and analyze data related to EPSDT and report this information to the federal government for monitoring purposes. These services are legal entitlements that the states must meet whether they are provided directly by the states or through their Medicaid managed care program.

Since most states have integrated EPSDT with their Medicaid managed care programs, the plans have the opportunity to help move the states closer to fulfilling the original purpose of EPSDT. There are, however, contradictions between EPSDT and managed care which can create some problems. Commercial managed care plans have historically used a narrower definition of medical necessity than EPSDT requires. Also, capitation arrangements can create a short term incentive to restrict the scope and intensity of services under the Medicaid provisions for EPSDT. Another example of the differences is the definition of case management. Health plans primarily consider case management a gatekeeping function. In contrast, the EPSDT requirements for case management stress providing support services (e.g., scheduling assistance and transportation) as well as coordination and referral to help children access a broad range of medical and other services.

The only aspect of the BBA relevant to preventive services is a comment made in the analysis report. The report notes that the Conference Committee had the opportunity to include additional requirements that were proposed in the Senate version of the bill, providing for example, requirements on transportation and translation services, extended hours of operation for primary care services, preventive and primary care in readily accessible locations, provision of information about other services and programs that enrollees might be eligible for, and other standards that the Secretary or state might have proposed. Unfortunately, these provisions did not make it into the final language of the bill.

According to the results of the 1996 NASHP survey, there is still quite a lot of variation in reporting requirements among states with risk-based programs. The survey did find that there is growing consensus about the needs for data collection among the states as well as the ability to utilize more information. Currently there are only reporting requirements for the risk-based programs, not the PCCM programs. Thirty-six of the 38 states with risk-based programs reported requiring encounter data for some or all services which is an increase from 22 states in 1994 and 26 states require reporting of aggregate utilization data. Twenty-seven states require the reporting of some version of HEDIS which is an increase from only 11 states in 1994. Eighteen states require outcomes/health indicator reporting (an increase from 15 in 1994). Also, 34 states require the reporting of grievances. There was no question related to this area on the 1994 survey.

In terms of quality measures, 26 of the 38 states with risk-based programs use the HCFA Quality Assurance Reform Initiative (QARI) guidelines as the standards for the health plan internal quality assurance programs (an increase from 17 states in 1994). Fifteen states use the National Committee on Quality Assurance (NCQA) guidelines. Seventeen of the states with PCCM programs reported tracking disenrollment from a particular primary care provider (a decrease from 19 states in 1994) and 20 states reported conducting physician specific utilization monitoring. There has also been an increase in ombudsman programs as a strategy to ensure quality. Ten states with risk-based programs and seven states with PCCM programs were operating ombudsman programs in 1996 (an increase from five risk-based and two PCCM programs in 1994).

In addition to these basic reporting requirements, the states are also concerned about ensuring that the Medicaid managed care plans meet the standards that the states have set and ensuring that these standards result in the desired outcome. There are many sources of information that states can use to determine if the program is achieving its goals. These sources include reviewing the required data submissions (as mentioned above), enrollment and disenrollment information, medical chart information, and other information outside the managed care system such as birth and death certificates plus discussion with and feedback from consumers and other stakeholders, The information from each of these sources measures different aspects of program and plan performance. Some of the information may be immediately applicable (such as grievances) and others (such as utilization data) may not provide information that is useful until enough information is gathered to measure change over time.

The types of measures most relevant to the discussion in this paper belong to two categories: process measures which examine whether the system is using procedures that are expected to result in the desired outcome (e.g., 70% of enrolled pregnant women should begin receiving prenatal care in the first trimester) and outcome measures which examine the results a system produces (e.g., 20% reduction of low birth-weight babies in two years). Process measures are the ones that states rely on most heavily throughout their managed care program operations. Sources of information used include utilization reports, medical chart reviews, enrollment and disenrollment reports, surveys, and complaints and grievances. The advantage of process measures is that they can be collected and reviewed relatively quickly after a program begins operation and in many cases they have been shown to directly result in desired outcomes (e.g., measles vaccinations are process measures that are certain to result in measles prevention). Their major drawback is that good performance on process measures is still not guaranteed to achieve the desired outcomes.

Outcome measures, on the other hand, provide the best indication of whether a plan or program is meeting its goals but outcomes often take years to produce and it is not always clear what factors contributed to the outcome. Even an outcome related to reducing the incidence of measles will not be measurable for several years after the childhood vaccinations take place. The waiting time is even longer for outcomes such as the reduction of deaths due to lung cancer. This problem is further complicated by the fact that Medicaid beneficiaries generally remain in one plan for only a short amount of time. Most states are using some form of program outcome measures in their programs because they are the best measure of whether a program is meeting its goals. Unfortunately, they cannot rely solely on outcome measures because of their severe limits in identifying problem areas in the short term.

One process measure that the federal government monitors for all state Medicaid programs is participation in EPSDT exams. State agencies must collect and analyze data related to EPSDT and report this information to the federal government whether the state is directly responsible for EPSDT or whether the EPSDT program has been integrated with the state’s Medicaid managed care program. There was only a brief reference to the state strategies for EPSDT in the NASHP survey report (Chapter 5 – Health Care for Children). The states typically use two types of standards for adequate outreach for EPSDT – outreach activities (e.g., sending a written notice to enrollees when EPSDT services are due, following up on missed appointments, etc.) and requiring a particular level of performance (e.g., requiring a set performance standard for age appropriate EPSDT exams). New Jersey’s program was mentioned as an example of a state that requires that both types of standards be met in their contractual arrangement with their Medicaid managed care program. Wisconsin is also mentioned in this chapter as an example of a state that uses an outcome approach with a financial penalty if the plan fails to produce the specified performance standard outcome.

Sixteen states (see note 1 at end of paper) reported that they are not doing any outreach beyond the current outreach being done by the Medicaid managed care program and/or Medicaid providers. The remaining 34 states reported that they are operating or funding additional outreach to increase the participation in EPSDT exams. Eighteen of these states (2) are directly operating some type of outreach program via a mailout of notices and reminders for EPSDT services, efforts of staff members with responsibility for EPSDT and/or interagency agreements with other state departments or agencies such as state health departments. Eleven states (3) are operating outreach programs via contracts with organizations at the statewide, regional and/or local level. These contracts are with organizations ranging from community based organizations (e.g., schools) to programs that also have interaction with the Medicaid population (e.g., WIC, Planned Parenthood) to county organizations and consortiums to statewide fiscal intermediaries. The remaining five states (4) operate outreach programs directly as well as contract for additional outreach services for EPSDT.

Peer outreach and education programs could provide significant assistance in the area of ensuring that the states and their Medicaid managed care plans meet the desired program process and outcome measures. For example, a plan may meet its process measure of providing enrollees with a member handbook within five days of enrollment but this does not ensure that the enrollee will read or understand the handbook. A peer outreach program could assist with achieving the desired outcome by providing one-on-one education about the plan and how to access services plus any follow-up required for education.

Peer outreach programs can assist with educating beneficiaries about the complaint/grievance process and reporting complaints that they receive. This process will help to resolve individual enrollee complaints and will also help increase the reporting of complaints and grievances which will allow states to identify issues that need further investigation. For example, a pattern of enrollee complaints about the inability to see a particular type of specialist within a specific plan could trigger the state to perform an interim review of the plan’s network to ensure that it is still in compliance with the standards for provider/enrollee ratios. Peer outreach programs could also assist with the completion of enrollee surveys which is generally used to examine enrollee satisfaction, the provision of care (e.g., waiting time for appointments) and system understanding such as knowledge of how to access EPSDT services. Only three of the 38 states with risk-based managed care programs reported NOT using some type of enrollee survey (whether performed by the state directly, their contracted health plans or an outside party).

Peer outreach programs can also provide assistance with meeting program outcomes. An example of this is a desired outcome of reducing low birthweight babies. The survey report states that mothers who do not get prenatal care are three times more likely to deliver a low birthweight baby. Medicaid managed care has the ability to deliver prenatal care to more women earlier in their pregnancies and thus could have a significant impact on birth outcomes. A critical step in the process of achieving this outcome, however, is to identify and enroll pregnant women early in the pregnancy. Effective outreach is key to this given the greater mobility of this population and the frequent lack of information about the services that are available to them and the importance of seeking early prenatal care.

A number of successful peer outreach programs have focused specifically on increasing prenatal care. The use of community residents in a peer outreach program helps overcome the geographic, cultural and language issues that can act as barriers to reaching this population and ensuring that these women obtain adequate prenatal care. In addition, outreach workers can help identify high risk women of child bearing age through contacts with community groups, churches, emergency food programs, shelters, and social service agencies. They can help women make appointments for regular prenatal care, they can make appropriate referrals for services to address other needs identified such as heating problems in the home, nutritional deficits, transportation problems and child care issues. They can also follow up with these women to ensure that they receive the help they need and that they keep their prenatal care appointments.

The BBA requires that states contracting with Medicaid managed care organizations develop a "quality assessment and improvement strategy" which is to include:

1. access standards to ensure that covered services are available within "reasonable time frames and in a manner than ensures continuity of care and adequate primary care and specialized services capacity"

2. other measures that are "directly related to the improvement of quality of care" (e.g., grievance procedures and marketing standards)

3. state monitoring procedures for evaluating the quality and appropriateness of care and services, including services for the "full spectrum" of enrollees

4. data collection by the state using the data and information set specified by the Secretary for use under Medicare+Choice Plans or any alternative data as approved by the Secretary in consultation with the state

5. regular and periodic reviews by the state of the scope and content of the strategy.

The quality assessment and improvement strategy is to be consistent with standards that are developed by the Secretary within one year after enactment of this section. Any standards that are enacted by the Secretary are not to preempt more stringent state quality assurance standards and any quality assurance standards that were included in the terms and conditions of a 1915 (b) waiver approved by HCFA are to remain in effect until the effective date of the Secretary’s standards.

This provision does help to fill a void since prior to the BBA, quality assurance procedures were found only in regulation which required contracts with managed care plans to provide for an internal quality review system. Unfortunately, it only applies to Medicaid risk-based programs and not to PCCM programs and the provision is still vague in terms of the guidelines for what is expected from contracting plans (e.g., there is nothing in the guidelines to require that plans and states uniformly report utilization and complaint data to allow for comparison of programs on a national level).

The BBA also gives the states the option to exempt a Medicaid managed care organization that is privately accredited from review activities that are duplicative of the accreditation process or the external reviews conducted under the Act. In addition, states have the option to waive the independent external review requirement for any Medicaid managed care organization that also is a Medicare managed care plan and has had a Medicaid managed care contract with the state for at least two years. In both cases, this is not considered a favorable provision by advocates for Medicaid because private accreditation agencies do not have experience in the Medicaid arena and because the population served under a Medicare HMO program is often very different from the population served under a Medicaid managed care plan. Quality monitoring of these plans via these other review vehicles "simply may not reflect the ability of the HMO to serve low-income Medicaid beneficiaries".

As a condition of federal financial participation in the state Medicaid program, states are required to hire recipients as employees. Specifically the Medicaid act requires state Medicaid agencies to provide for the training and effective use of staff with particular emphasis on the full-time or part-time employment of recipients and other persons of low income, as community service aids in the administration of the plan, and for the use of nonpaid or partially paid volunteers in a social service volunteer program in providing services to applicants and recipients. In a special 1996 report on required and voluntary mechanisms used in Medicaid managed care programs, there was no widespread evidence found that this provision has been implemented in spite of the legal mandate to do so. In fact, the findings from interviews and a review of legal documents were that this federal law is infrequently used and its existence not well known. A review was also made of the managed care contracts and state RFP’s. They found only six (HI, OR, PA, RI, TX, and VT) that mentioned the hiring of recipient employees by Medicaid-participating health plans and with the exception of Pennsylvania, they concluded that these provisions do not appear to be in response to the federal law.

The 1996 survey of state Medicaid managed care initiatives did find that fifteen risk programs and ten PCCM programs use consumer groups to outreach, educate and promote enrollment. The report also noted that seven states reported the use of indigenous outreach workers on site (AZ, CT, DE, NE, NY, UT, and WI) and nine states reported the use of outreach workers for home follow-up visits (CT, DE, DC, HI, NE, NJ, NY, PA, and WI).

It was noted that several health plans have hired and trained former Medicaid enrollees as customer service representatives and outreach workers. An example of this is Managed Health Services in Wisconsin hiring AFDC beneficiaries to perform outreach activities for Medicaid enrollees (a technique that is being implemented by the parent company - Centene Corporation - for all of its Medicaid contracts). Another example noted in the report is Utah’s use of state Medicaid workers as health program representatives. These workers are located in the welfare eligibility offices and they conduct education, counseling, enrollment, disenrollment, and handle complaints for members of special Medicaid populations. It was learned via a phone call to the Utah Medicaid office that the state has employed these health program representatives since 1983 which is before the federal mandate was put into place. These workers in Utah serve all segments of the Medicaid population, not just those from the special populations.

The community health worker concept is a form of peer outreach and education and one which can involve the employment of Medicaid recipients. In a leadership brief prepared by the Codman Square Health Center on preventive health programs, a Community Health Worker (CHW) is defined as community members who educate and serve individuals and groups to gain greater control over their health and their lives. CHWs are recruited not only for their abilities but also because they share experience or culture with the communities they serve. As community members, they are able to translate health information about prevention and the health system into the community’s culture, language and value system - something critical to the success of the Medicaid managed care program. In the section of the brief on State Policy - Medicaid Purchasing and Reimbursement, the following was noted related to reimbursement for CHW services:

Wisconsin: Wisconsin appears to be on the way to providing Medicaid reimbursement for CHWs providing certain Maternal and Child Health Services.

Indiana: Maternal and Child Health CHW programs advocated for a legislative change to their Medicaid plan which resulted in Medicaid reimbursement for CHW visits for certain prenatal access and monitoring functions.

Washington: There has been a Medicaid waiver in place for at least the past two years that allows for limited reimbursement for CHW services related to maternal and child health.

It is interesting to note that neither Indiana or Washington responded in the 1996 Survey of State Medicaid Managed Care Initiatives that they use indigenous community outreach workers on site or that they use outreach workers for home follow-up visits. Washington did report that they use consumer groups for client education (which may include the above program for maternal and child health CHW services) but Indiana did not even report affirmatively in this area of the survey.

There was nothing found in the analysis report on the BBA regarding any changes to the Medicaid requirement for hiring recipient employees. Thus, it appears that all of the federal Medicaid Act and regulatory provisions for consumer involvement remain in full force and effect in spite of the weak implementation of this provision among the states.